20040273 (2).pdfr DAT� RECEIVE
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAME/NAME OF BUSINESS
MAILING ADDRESS
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CITY ZIP TELEPHONE
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NAME
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ADDRESS
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CITY
NAME
ADDRESS
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STATE LICENSE NUMBER
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PLAT NAVPSUBDIVI SION NO
PERMIT EXPIRES
PERMIT
N U M B E
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LID FEE S
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, ESCP Approved
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PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
RW Permit Required
0
street Use Permit Req a
13
EXISTING — PROPOSED
inspection Requited
0
sidewalk Required
0
REQUIRED DEDICATION— FT
Underground
0
Wiring required
METER SIZE
LINE SIZE
OF FIXTURES
PRV REOl IRED
FYES
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NEW
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PLUMBING / MECH
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ADDITION
COMMERCIAL
COMPLIANCE OR
CHANGE OF USE
REMODEL
APARTMENT
SIGN
REPAIR
GRADING
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FENCE
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GARAGE
RETAININGWALL
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NUMBER OF
CRITICAL
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DWELLING
AREAS
NUMBER
or STORIES
UNITS
1 DESCRIBE WORK TO BE DONE
[_HEATS'OURCE GLAZING 9. LOT SLOPE
PLAN CHECK NO: —[VESTED DATE
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
t BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC
DOMAIN (CURBS. SIDEWALKS, DRIVEWAYS, MARQUEES. ETC.) WILL REQUIRE
SEPARATE PERMISSION.
a: PERMIT APPLICATION: 180 DAYS
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PERMIT LIMIT: 1 YEAR - PROVIDED WORK IS STARTED WITHIN 180 DAYS
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
in "APPLICANT. ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESORS
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w IN INTEREST, AGREES TO INDEMNIFY. DEFEND AND HOLD HARMLESS THE CITY OF
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2 EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES. AND AGENTS FROM ANY AND
ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLY OR INDIREC I LY
FROM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS PERN41T SHALL NOT BE
0 DEEMED TO MODIFY. WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
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0 NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION,
I HEREBY ACKNOWLEDGE THAT I HAVE READ 1 HIS APPLICATION. THAT THE INFORMATION
GIVEN IS CORRECl: AND THAT I AM THE OWNER, OR THE DULY AUl HORIZED AGENT OF
THE OWNER. I AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC-
TION, AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING 10
WORKMEN'S COVFNSATION INSURANCE AND RCW 18.27
DATE SIGNED
SIGNAlUREfOWNEJOPAGPH�7 I I I
................
REMARKS
OWNE R 'CONTRACTOR RESPONSIBLE FOR EROSION CONTROL/DRAINAGE
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ENGINEERING
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FIRE REVIEWED B't
REVIEWED/DATE
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DATE
OR CU SHORELINE OR ADB# INSPECTION BOND
REO'D POSTED
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SPECIAL INSPECTOR JAREA
REQUIRED [] YES
GROUP
OCCUPANT
LOAD
REMARKS
PROGRESS INSPECTIONS PER UBC 108/FINAL INSPECTION REAQ'D
ATTENTION
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI-
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109
5:96
VALUATION
PLAN CHECK FEE
BUILDING
PLUMBING
MECHANICAL
GRADINGiFILL
'�'TAT "_ U R C I I A R C. E
ENG REVIEW FEES
ENG INSPEC11ON FEE
LANDSCAPING
INSPECTION FEE
PLAN CHECK DEPOSIT I RECEIPT
TOTAL AMOUNT DUE
CALL
FOR INSPECTION
(425)
771-0220
EXT 333
771-0221
FAX
FEE
APPLICATION APPROVAL
This j1pplucation is not a permit until signed by the
Building 011icial or his/her Deputy and Fees are Paid. and
receipt is acknowledged in space provided
OFFICIA)_S SSIGNii),TURE DATE
VI—I&I �j
RELEP6ED BY I DAl E
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ORIGINAL - FILE YELLOW - INSP ;COF4,
PINK - OWNER GOLD - ASSESSOR
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.11NALA."ROJECTAPPROVAL FORM,
TO:
MEMOTO: PE�RMIT COORDINATOR, BUILDING DIVISION
FROM:
PROfECT.
FIRE DEPARTME-NT DATE
I'LLASE SIGN
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0k_1911, ENGINEERINGDIVISfON DATE
VPLEASE SIG14
PLCASFSIGN
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PLANNING DIVISION DATE
SITE ADDRESS 74� V 6Z_
PE RMIT HZJZ��4 ADBY. DATEL INSPECTED
DESCRIPTION OF WORK TO BE INSPECTED
A field inspection was conducted to determine compliance with -approved plans. Final app rioval
denotes that there are no objections from the -above signed Department to the release of
PERI[i'ORMANCE BONDS and the granting of
GRANT FINAL PROM CT APPROVAL
GRANT PROJECT APPROVAL WITH CONDITIONS NOTED
0 Copy of CONDITIONS given to owner/contraclor by inspector
FAILED FINAL INSPECTION - OUTSTANDING ISSUES
0 Copy of CORRECTION NOTICE given to owner/contractor by inpector
2.
3.
RE-LNSPECTED OUTSTANDING ISSUES - GRANT FINAL PROJECTAPPROVAL
Date Signature
1:tetnp:b1dg:fonw%:ocaprv1 3/25/04
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RECORD OF INSPECTIONS
INSPECTOR DATE APPROVED
SETBACKS .....................
FOUNDATION:
Footing ......................
Wall..........................
Pier/Porch .................
Retaining Wall ........... z
0
Slab Insulation .......... 4
PLUMBING:
Underground .............
Rough -in ................... :E
M
C
Commercial Final ...... M
0
—40
HEATING: 0 C
-C M
Gas Test .................... M Z
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Gas Piping ................. C
Equipment ................. x
Commercial Final .......
0 -n
n
EXTERIOR SHEATHING --I
NAILING .......................... x
M M
FRAMING ........................ 0
OM
C Cn
FIRST FLOOR FRAMING ... 9 C/)
Q 0
INSULATION ................... Z r—
Floor Insulation ......... ;U
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Wall Insulation ........... 3:
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Ceiling Insulation ....... —i
3:
SHEETROCK NAILING ... Cn
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SPECIAL INSPECTION ... 0
1
0
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MISCELLANEOUS ..........
FINAL APPROVAL FeR
titmerofty ..................
SideSewer#
AmoutPald$ 2 c
k A) INVIAR
Datebsued
Water Meter Size
Amountftid (�Mo Rcmlln".'
Date PurchnsA 73v
r.;.Ow#
Amount